In 2007, supported by an extraordinary team of family, friends, and medical staff, I stomped the snot out of a nasty cancer that was on its way to killing me. I've since learned that the way I did it has a lot in common with the advice of the "e-patients" movement, so I've changed my blogger name from Patient Dave to e-Patient Dave.

Wednesday, May 20, 2009

On Tuesday I was invited onto a blogger conference call hosted by IBM to discuss the Medical Home concept. I was immensely happy that IBM had the vision to invite a plain old ordinary patient to be on the call. Good for them!

As longtime readers know, I've written about the medical home concept several times. It's about the fact that so many people lack a plain old ordinary doctor's office where they KNOW you – a medical "home," as it were. (Or, as they say on Cheers, "Where everybody knows your name.")

Everyone else on the call was "in the business," and as it happens, the slides were far more "in the business-y" than I would have preferred. (They're posted below.) To get a concept like this into the skulls of the Very Smart Important People in government, it seems they have to talk in abstractions and Big Principles.

Suggestion: How about also including some street reality common sense facts? Like, people who have a medical home are half as likely to have a heart attack! That statistic was mentioned (in passing!) by IBM's Dr. Paul Grundy (who's become something of a buddy of mine) at the start of the call, but wasn't considered relevant enough to put in the slides!

See, IBM employs a LOT of people so they have a LOT of data about what works. 6-8% of their insured employees are in a Medical Home plan, and that's the result IBM has seen.

Wouldn't you like to be in a plan with that kind of results? Doesn't cost anymore, either. So what the heck is everyone else thinking, and what are they waiting for?

9 comments:

Thanks Dave you are so right on target -- we are starting to get some information on the financial Impact of practice transformation. This from transforMED)

Publication of results from TransforMED's National Demonstration Project (NDP) began last week with the article, "Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home" in the May/June issue of Annals of Family Medicine.TransforMED launched its two-year National Demonstration Project in 2006 and included primary care practices from around the country, studying the process of transforming to a Patient-Centered Medial Home. Additional articles on the outcome of this one-of-a-kind national study will continue to be published, including an extensive supplement to AFM scheduled for publication later this year. Congruent with the efforts of the NDP evaluation team, TransforMED has studied targeted financial data gathered from the NDP practices. The data demonstrate some critical findings about the impacts of practice transformation.

“There has been debate about whether small to medium sized practices can transform to a patient centered model of care. The answer from the NDP is a resounding "Yes!"”

There has been debate about whether small to medium sized practices can transform to a patient centered model of care. The answer from the NDP is a resounding "Yes!" There has also been an ongoing question about whether small to medium sized practices can implement an Electronic Health Record system effectively and efficiently. Again the evidence from the NDP is a resonating "Yes!"

Another national discussion is whether primary care practices can afford to transform; calling into question the financial impact on practices. The Evaluation Team's analysis of the NDP indicates that primary care practices can make substantial progress toward implementing components of the Patient-Centered Medical Home model. TransforMED's analysis of financial data gathered throughout the study reveal that they can do so while improving the finances of the practice as well as physician salaries. It is worth noting that about 70% of practices had an implemented EMR at the beginning of the project, and as a result many of the practices were also implementing EMR systems during the NDP. The analysis of financial data from the NDP demonstrates that practices do not have to experience a reduction in practice revenue as a result of meaningful practice transformation. In fact, the average NDP facilitated practice revenue increased 10.49% and 2.43% in the self-directed practices. Furthermore, physician salaries increased nearly 14% in facilitated practices and 13% in the self-directed practices. It can be deduced that the revenue and salary increases reflect increased efficiency because physician salaries actually rose at a greater percentage than the practice's increase in revenue.

These data demonstrate that primary care practices can accomplish meaningful, extensive practice transformation. Adequate attention to the "business of medicine" and effective practice management can lead to improved revenue and increased efficiency thus allowing the practice to absorb the cost of change and technology while improving the bottom line. Future data will most likely continue to demonstrate improved practice revenue and physician income as practices move past the challenges of transformation while providing solutions to the challenges facing the US Healthcare system.

Everyone, that comment is from Paul Grundy MD himself, the chair of PCPCC and Director of Healthcare Technology and Strategic Initiatives, in IBM's corporate HQ Global Well Being Services & Health Benefits.

Paul, thank you so much, for that comment and for everything you're doing.

I hope folks will dig through what Paul wrote. It's a bit deep for me, especially since I'm not steeped in the long and hairy history of arguments about whether "medical home" is a feasible thing for existing offices to try. But what I'm hearing Paul say is that the answer is "Yes."

This is a Big Deal, because a year ago the powers that be finally agreed to do a "demonstrationi project" - a small-scale test, if you will, to see if the Medical Home concept actually works and see if it's feasible for a medical practice (office) to make the switch. Paul's saying that the first results are in, and the answer is Yes.

And now I see that slide deck in a different light: the report concludes that there is no longer any reason to delay moving to a Medical Home approach, nationally.

Presuming this pans out, it'll mean that we (you and I) will have reason to start nudging (or noodging!) our policy people and our hospitals and doctors to move in that direction. Grass roots!

Even if you're already at a place where they know you (as I am), we can still be citizen voices calling for this to be the new standard. Let's.

Let me first resoundingly echo Paul's comments regarding the ability of solo and small practices to trasform and deliver excellent care.

Let me gently point out that the excellent and wonderful TransforMED project is not the only game in town and that other solo/small projects have demonstrated striking improvements in care and published their results (see www.IdealMedicalPractices.org).

Let me suggest that we be very careful to not fall into the all-too-common medical trap of treating people as organ systems or diseases - an excellent diabetes program or excellent several-chronic-condition management is not the foundation of high performing health systems.

Decades of studies tell us that effective comprehensive accessible primary care is what leads to better health outcomes, better experience of care and reduced costs of care (because we avoid unnecessary care and missed opportunities for prevention & early intervention).

The easiest way to recognize the presence of such care is to ask the people in the practices about their experience. Based on published data, excellent primary care is in evidence when the patients say:"I can get care when and how I need it""I have a PCP/team who knows me as a person""My PCP/team care for the bulk of my needs""My PCP/team coordinate any care I need in the wider health system"

We need to stop mystifying and overly complicating the definition of good care that leads to good outcomes. It is time to start listening to the people we serve.

I am eagerly looking forward to the day when the public/patients demand their rightful voice in defining the quality of the care they receive.

Great to hear from you, Gordon. (Folks, this is Twitter user @GMoore1960, author of the Ideal Medical Practices blog. A right-minded guy; if you want to get your blood boiling about the insanity of today's system, read his post Why Times Are Dark. Disgusting story of insurance idiots blocking care delivery, causing harm to patients.)

So, Gordon, are you saying Paul's report is a validation of other reports, a continuation, or something else? My impression is that PCPCC is trying to maneuver the industry into getting off its butt and getting the job done, medically. Your thoughts?

The PCPCC is indeed a powerful and right-minded move to help lend industry weight to breaking the gridlock of the status quo.

The TransforMED work is excellent and adds more substance to the growing experience that there are practices once again willing to step up to plate and make dramatic changes to better serve their patients.

My comments about the measurement and the disease/organ system approach gets at an inside-the-industry flaw in logic that leads too many of my bright and caring colleagues into the trap of myopia.

I'm not at all calling out Paul, the PCPCC, or the TransforMED project but I am calling out the health industry's current approach to defining the 'medical home' as a set of IT and processes that almost totally ignore the voice of those served.

This flaw is substantive in that practices may currently earn top tier recognition from the NCQA but do little of substance to fix fundamental flaws in their delivery of effective primary care.

If we continue to use this flawed yardstick then the planned medical home demonstration projects will spend a lot of time and money in pursuit of trivia. This would be not only a shame but would set back transformation of the delivery system.

The key to solving this problem is to recognize the experience of those served as defining the degree to which a practice has built a solid foundation of care.

We must move into the post-Copernican world of defining primary care with the patient finally recognized as the center of the solar system.

Boy, I'm glad I asked, Gordon, because I wouldn't at all have come away with that conclusion.

So now please help me see the next step in your thinking: what's missing in the Medical Home demonstration project, that keeps it from boosting "the experience of those served as defining the degree to which a practice has built a solid foundation of care"?

It seems to me (from the patient's perspective of course) that the outcome (half as likely to have a heart attack) is an obvious priority. But are you saying that's not being used as a criterion and should?

I'm right there with you on the collaboration/relationship being the center.My work in re-defining the primary care delivery system stems in part from Dartmouth's Microsystems: the 'smallest replicable unit' of effective primary care is the patient, the PCP&team, and the IT that weaves them together.This gets at the measures.The outcomes we need are clinical improvement (e.g. "half as likely to have a heart attack"), improved experience of care (e.g. "I can get care when and how I need it") and reduced costs of care (e.g. "half as likely to be hospitalized or end up in the emergency department").What I'm addressing are the technical details around the question "Given finite time and resources, where am I most likely to get the greatest improvement for the most people?"I've worked for years teaching practices how to improve chronic care delivery, improve efficiency, measure results. When we use a disease specific approach to improve clinical care we almost always end up with a practice delivering improved care for that limited condition and no spread to other conditions. We've failed time and again to achieve the system level practice improvement this way, yet I see once again that most 'medical home' projects are organized around one, two, or sometimes three 'conditions' and predict that they will fail to achieve meaningful improvement beyond these limits.Don't get me wrong - any improvement is great and I love to see that people with diabetes are getting better care, but what about the 90-95% of patients in the practice who don't have diabetes? Why don't they deserve better care?The next flaw in the current demonstration projects is the lack of attention to the fundamentals of effective primary care:Eliminate barrier to access - open electronic portals so that patients have unfettered access to their team and eliminate waits and delaysEnable and support excellent relationships over time - connect patients with a small, tightly coordinated and highly personal team who knows the patient as a person and treats them with dignity and respect.Provide a comprehensive array of services - expand services to include true self-management support and other services.Coordinate care to create a seamless transition across the health care system.It turns out that when these four things are done well we see all sorts of good results:Improved clinical outcomes (reduced blood sugar for people with diabetes, reduced blood pressure, etc)Improved experience of care (people say "my care is perfect" etc)Reduced costs of care (significant reduction in emergency room visits and hospitalization).These results are across-the-board and not sequestered to a handful of people with a particular diagnosis.I'm not looking for an 'either-or' here, we can use typical medical measures that the medical industry is used to seeing, but rather than relegate these critical variables to the obscurity imposed by the NCQA framework, let's call them out as fundamental, important, and actionable.Practices in the IdealMedicalPractices project were able to use patient experience data to change the way the practices worked and to improve care.This is a powerful way to steer practice improvement, unmask opportunity to improve, and to get patients and their doctors/care teams on the same page about what matters.

Gorden your point is “most excellent” it is so cool -- lots and lots of folks stepping up to practice transformation Ideal Medical Practices is one worth looking at !!! L. Gordon Moore is an Assistant Professor of Family Medicine; University of Rochester School of Medicine and is really doing some very cool stuff I have meet some of the doctors who have trained at Rochester they are really top notch I hope to visit in June. The point Dr Gorden makes is that it is way more than TransforMED or the PCPCC www.pcpcc.net is happening there really are a thousand flowers blooming. I am heading down to more to Atlanta next week and I have been very impressed with the work of David Satcher and the and National Center for Primary Care http://web.msm.edu/ncpc/mission.htm at Morehouse. I love the work out of the Center for Excellence in Primary care www.ucsf.edu/cepc/ and Laurence Bauer’s Family Medicine Education Consortium http://www.fmec.net/about/index.asp,ACP Medical Home Builder, MacColl Institute for Healthcare Innovation, ABMS: Improving Performance in Practice (www.abms.org)and many many more.

Look the primary care doc like Dr Gorden themselves stepping up doing the hard dirty work of practice transformation on the micro level gives me real hope in the USA. For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.

A few of us (who are the employer large buyer) are driving as hard as we can on the Macro reform and we need to do so much more to help.

Frankly the foundation we found that can allow us to address healthcare in a much more rational way with a much more powerful integration of wellness and prevention is a trusting long term doctor/patient relationship. If one is lucky enough to have such a trusting relationship tough choices can addressed honestly and frankly. Without that kind of relationship we find our employees are much more likely to be given unneeded, often times toxic services and much less likely to engage in preventive services and get needed recommend services like screening etc.

When someone has a primary care doctor as their usual source of care their healthcare cost 33% less and they have a 19% lower mortality. So IBM is driving very hard to get comprehensive primary care and prevention for our employees, their families and for society at large when we reach out to all of organized primary care and asked for this they agreed to deliver it in the form of moving to a Patient centered medical home model of care.

I like Dr Gorden are happy to see my patient get better care anyway that it come but feel very strongly that in the long run the patient is best served when the care is delivered in a trusting relationship and the focus is on the patient not the disease.